When a patient chooses the Medicare hospice benefit, the standard Part B rules implication stops. Medicare straight up denies claims submitted without a GV or GW modifier (condition code 07) during the process of hospice election. This is assigned as provider liability which means you cannot bill the patient anymore.
The GV modifier is for services that are provided by the patient’s attending physician for care that is related to the terminal illness, not employed by the hospice. The GW modifier, on the other hand, is used to indicate care that is not related to terminal illness (provided by any caregiver). Let’s look at the GV vs GW modifier application for Medicare.
Why Medicare Requires Hospice Modifiers
Medicare Part A covers hospice. The hospice receives a bundled per-diem payment for all hospice-related services associated with the terminal illness, including the professional services of the hospice physicians, therapy, symptom-management medications, supplies and equipment, and nursing.
If a beneficiary chooses hospice, he or she does not have to pay Part B for hospice services, except for the professional services of the beneficiary’s designated attending physician. The Medicare hospice modifiers are intended to let the claim system know if a specific service is to be paid separately from the hospice bundle.
What is the GV Modifier for Medicare?
According to the official GV modifier description: “Attending physician not employed or paid under arrangement by the patient’s hospice provider.
By adding GV, two things are being conveyed to Medicare at once:
- The service is being provided to the patient who has the terminal condition.
- That the service is being provided by the attending physician who is caring for the patient, and not by the hospice.
If both are true, Medicare will pay the claim under the Medicare Part B benefit.
When and When Not to Use the GV Modifier
| When to Use GV | When NOT to Use GV |
|---|---|
| Patient has an active Medicare hospice election on the date of service | Provider is employed by or volunteering for the hospice |
| Billing provider is the attending named on the hospice election form | Provider is not the designated attending on the hospice election form |
| The service treats or manages the terminal illness or a related condition | The service is unrelated to the terminal illness so GW applies instead |
| Provider is not employed or paid under arrangement by the hospice | The service is a technical component or lab test billed to the hospice |
Who Can Bill With the GV Modifier
The attending role extends beyond physicians as Medicare recognizes three types of providers:
- Physicians (MD/DO) paid at 100%
- Nurse practitioners are paid at 85%
- Physician assistants
What Is a GW Modifier for Medicare?
The official descriptor of the modifier GW is, “Services not related to the hospice patient’s terminal condition.” Where GV answers who is billing, GW answers what is being treated and billed. Any provider caring for a hospice patient’s unrelated condition uses it, including the attending physician, whenever a visit addresses something disconnected.
When and When Not to Use the GV Modifier
| When to Use GW | When NOT to Use GW |
|---|---|
| Patient has an active Medicare hospice election on the date of service | The condition was caused or worsened by the terminal illness |
| The service addresses a condition unrelated to the terminal illness | Documentation cannot clearly support why the service is unrelated |
| Any Medicare provider treating the patient can bill it | The claim is institutional and needs condition code 07 instead |
| An ER physician treats a wrist fracture for an end stage cancer patient | It is applied to every claim just to force payment from Medicare |
Documentation Requirements for GW
Because GW routes payments around the hospice benefit, it attracts high scrutiny. The records should be simple and straightforward about why the service is unrelated.
However, if the documentation leaves that relationship ambiguous, expect an upfront denial. A single clear sentence in the record is enough rather than pages of clinical details.
GV vs GW Modifier
The difference between the GV and GW modifiers is basically about who is billing and what they are treating. For a detailed comparison, read this table:
| Aspects | Modifier GV | Modifier GW |
|---|---|---|
| Relationship to terminal illness | Service is related to the terminal condition | Service is unrelated to the terminal condition |
| Who can bill it | Only the designated attending (MD, DO, NP, or PA) not employed by the hospice | Any Medicare provider treating the patient |
| Claim type | Professional claims (CMS-1500) | Professional claims; institutional claims use condition code 07 |
| What it tells Medicare | Pay the attending’s related care under Part B despite the election | Pay this service under normal Part B rules |
| Example | Attending PCP manages end-stage COPD symptoms | ER physician treats a wrist fracture for a hospice cancer patient |
Conclusion
There are two questions to go through with every claim for a hospice patient. Is the service related to terminal illness? And is the attending provider billing the provider, and not employed by a hospice? Attending care is for GV for related care and GW or condition code 07 for unrelated care from any provider.
If you can answer those two questions correctly, the modifiers take care of themselves. If you get them incorrect, the denial becomes provider liability, which you can’t bill to the patient. If hospice denials continue to return, MedCare MSO’s hospice billing services can assist you in creating clean eligibility checks, modifier logic, and documentation workflows. Contact us now and let us tell you how we can be of help.
